Scaphoid Injury Clinical Presentation

Updated: Sep 11, 2019
  • Author: Scott R Laker, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Presentation

History

Scaphoid fracture can occur through two different mechanisms: a compression injury or a hyperextension (ie, bending) injury.

  • The compression injury originates from a longitudinal load or impaction of the wrist, which often leads to fracture of the scaphoid without displacement.
  • In a hyperextension injury, when tensile stresses generated and applied to the wrist exceed bone strength, a displaced fracture commonly results.

  • Other fractures or dislocations of the carpus and forearm occur in 17% of patients.

  • In many wrist sprain injuries, the dorsal rim of the radius and the waist of the scaphoid abut, resulting in a contusion of the scaphoid, or even the capsule, with resulting pain that can be provoked by deep palpation in the snuffbox.

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Physical

The patient with a scaphoid fracture often presents complaining of wrist pain and may be diagnosed as having a sprain of the wrist. In sports-related injuries, it is not uncommon for a fractured scaphoid to go unnoticed. Pain and tenderness are often on the radial side of the wrist. Pain often is exacerbated with wrist motion. 

  • For distal pole fractures, a reliable correlation exists with pain provoked by deep palpation at the volar tubercle of the scaphoid, which is the first bony prominence distal to the volar distal radius.
  • For waist fractures, focal tenderness is most often found in the anatomic snuffbox.
  • For proximal pole fractures, tenderness is often found just distal to the Lister tubercle.
  • A high positive correlation with scaphoid fracture exists when there is tenderness upon palpation at the snuffbox and volar tubercle.
  • Scaphoid fracture is not very likely when tubercle palpation does not provoke pain in the snuffbox.
  • Range of motion (ROM) is reduced, but not dramatically.
  • Swelling around the radial and posterior aspects of the wrist is common. If high forces are associated with the injury, ligamentous trauma is also possible.
  • These same findings may be present with ligamentous injuries of the wrist; thus, whenever findings are suggestive of a scaphoid fracture, the patient should be treated for a scaphoid fracture.

One systematic review found the history not to be useful for diagnosis, but absence of scaphoid tenderness and absence of pain with resisted supination had negative likelihood ratios of 0.15 and 0.9, respectively. [9]

Special provocation maneuvers

See the list below:

  • Watson (scaphoid shift) test

    • The patient sits with the forearm pronated. The examiner takes the patient's wrist into full ulnar deviation and extension. The examiner presses the patient's thumb with his/her other hand and then begins radial deviation and flexion of the patient's hand.

    • If the scaphoid and lunate are unstable, the dorsal pole of the scaphoid subluxes over the dorsal rim of the radius and the patient complains of pain, indicating a positive test.

  • Scaphoid stress test

    • The patient sits while the examiner holds the patient's wrist with one hand, with the examiner applying pressure with his/her thumb over the patient's distal scaphoid. The patient then attempts radial deviation of the wrist.

    • If excessive laxity is present, the scaphoid is forced dorsally out of the scaphoid fossa of the radius with a resulting audible clunk and pain, indicating a positive test.

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Causes

Scaphoid fractures usually are an injury of young men and women, occurring after a fall, athletic injury, or motor vehicle accident. [10]

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